Background: Endovascular aneurysm repair (EVAR) and open surgical repair (OSR) are definitive treatment of choice for infrarenal abdominal aortic aneurysm (AAA). EVAR has demonstrated reduced peri-operative mortality but issues persist with late rupture, reintervention and long term durability versus OSR. Materials and Methods: We conducted a multicenter, retrospective cohort of patients who underwent elective EVAR and OSR between January 2015 and December 2020 with follow-up to June 2025. Primary outcome was all-cause mortality at 6 years; secondary outcomes were 30-day mortality/complications, ARM (aneurysm-related mortality), late rupture, reintervention, sac behavior and surveillance burden. Cox and Fine–Gray multivariable models were adjusted for age, sex, ASA class, aneurysm diameter, renal function and smoking. Results: Among 1,040 patients (EVAR 640; OSR 400), EVAR had lower 30-day mortality (1.4% vs 3.8%) and complications (18% vs 32%), but higher 6-year all-cause mortality (29% vs 24%), late rupture (3.9% vs 1.8%), and reintervention (16% vs 9%). Sac regression ≥5 mm at 1 year was found in 54% after EVAR and associated with improved long-term survival and fewer reinterventions. The rate of surveillance imaging encounters was ~2.4× higher with EVAR. Conclusion: EVAR confers an early survival/complication advantage but demands lifelong surveillance and has higher late failure signals (reintervention and rupture) than OSR. Patient selection, adherence to device instructions for use, and sac-based risk-adapted follow-up are key to optimizing long-term outcomes.
Elective repair of infrarenal AAA is indicated once the rupture risk exceeds operative risk, commonly at a diameter threshold of ≥5.5 cm in men and slightly lower in selected women and rapid expanders. Contemporary guidelines acknowledge that EVAR has largely supplanted OSR in many regions due to lower peri-operative mortality and faster recovery, while emphasizing the need for lifelong surveillance after EVAR because of device-related failure modes.1-3
Randomized trials comparing EVAR with OSR demonstrated an early survival advantage for EVAR that diminishes over time, with late hazards related to endoleak, sac expansion, and secondary procedures. The EVAR-1 15-year follow-up reported higher late aneurysm-related mortality and reintervention after EVAR despite its early benefit. 4 The DREAM trial’s extended follow-up similarly found no long-term survival difference but a persistent excess of reinterventions in the EVAR arm. 5 By contrast, the VA OVER trial’s extended analysis showed similar long-term overall survival between strategies, again with more secondary procedures after EVAR, underscoring that long-term differences may be sensitive to case mix and surveillance intensity. 6
Large registry and claims-based studies have complemented trial data. A Medicare-matched cohort (n = 32,760) showed EVAR with lower 30-day risk but higher 6-year mortality, rupture, and reintervention than OSR, suggesting durability advantages to open repair at long horizons.7 Conversely, umbrella and meta-analytic syntheses confirm EVAR’s consistent peri-operative advantage and show broadly comparable long-term survival between strategies when contemporary devices and follow-up protocols are considered. 8
Post-EVAR sac dynamics are powerful prognostic markers: failure of sac regression (or sac expansion) at 1–2 years correlates with late mortality, rupture, and reintervention, enabling risk-adapted imaging schedules. 9 Recognizing this, the 2024 ESVS guidelines endorse individualized surveillance and careful adherence to instructions for use (IFU), particularly in hostile neck anatomy, where EVAR failure risks escalate. 10
Despite extensive literature, uncertainties remain: how to optimize selection between EVAR and OSR in younger/low-risk patients; the long-term risks of late rupture after EVAR; and economic trade-offs given EVAR’s surveillance and reintervention burden versus OSR’s higher index morbidity. 11 We therefore report a multicenter cohort (2015–2020 repairs; follow-up to mid-2025) comparing long-term outcomes of EVAR vs OSR with a focus on survival, aneurysm-specific events, sac behavior, and care utilization, aligned with contemporary guideline concepts. 12.
This is a Multicenter retrospective cohort of consecutive adults undergoing elective infrarenal AAA repair (EVAR or OSR) at three tertiary vascular centers from Jan 1, 2015 to Dec 31, 2020, with vital status and clinical follow-up through June 30, 2025.
Inclusion criteria
Exclusion criteria
Endpoints
Primary: All-cause mortality at 6 years post-procedure.
Secondary: 30-day mortality; major complications (cardiac, pulmonary, renal, bowel ischemia, wound, bleeding reoperation); length of stay; aneurysm-related mortality (ARM); late rupture; secondary therapeutic procedures (endovascular or open conversions); sac behavior on surveillance (regression ≥5 mm, stability, expansion ≥5 mm at 1–2 years); and surveillance utilization (imaging encounters/patient-year).
Data sources and definitions
Prospectively maintained institutional registries cross-linked to electronic health records and state death indices. Complications defined by SVS reporting standards. Sac change referenced to pre-discharge CTA; ≥5 mm threshold adopted for regression/expansion. Surveillance protocols: EVAR at 1 mo, 12 mo, then annually (CTA or duplex per center/device); OSR at surgeon discretion (typically 5-year interval). Deviations captured.
Statistical analysis
Baseline characteristics summarized as mean ± SD/median (IQR) and counts (%). Between-group comparisons used t-test/Mann–Whitney and χ²/Fisher as appropriate. time-to-event with log-rank tests; cause-specific and subdistribution hazards (Fine–Gray) for ARM/rupture adjusting for competing death. Proportional hazards analyzed; Multivariable Cox model adjusted for age, sex, ASA class, diameter, eGFR smoking COPD and CAD; P value less than 0.05 was considered as statistically significant. Reintervention analyzed with Andersen–Gill models. Missing covariates (<5%) were imputed using chained equations (m = 10). Two-sided α = 0.05. Analyses performed in R 4.3.
Ethics
The study was approved by the institutional review board with a waiver of consent for retrospective analysis, and reporting complies with STROBE and modern guideline presentations.
Table 1. Baseline characteristics (EVAR vs OSR)
|
Variable |
EVAR (n=640) |
OSR (n=400) |
p-value |
|
Age, years (mean ± SD) |
73.1 ± 7.2 |
69.4 ± 7.9 |
<0.001 |
|
Female, % |
14.7 |
17.0 |
0.29 |
|
Aneurysm diameter, mm (mean ± SD) |
59.6 ± 6.5 |
60.8 ± 6.3 |
0.01 |
|
Current smoker, % |
42.8 |
39.0 |
0.23 |
|
CAD, % |
38.4 |
35.8 |
0.38 |
|
eGFR <60 mL/min/1.73 m², % |
24.2 |
18.0 |
0.02 |
|
ASA class III–IV, % |
67.0 |
49.5 |
<0.001 |
EVAR patients were older and higher risk (ASA, CKD), consistent with the selection patterns of modern practice.
Table 2. Peri-operative outcomes (30-day)
|
Outcome |
EVAR |
OSR |
p-value |
|
Mortality, % |
1.4 |
3.8 |
0.02 |
|
Any major complication, % |
18.1 |
32.0 |
<0.001 |
|
Myocardial infarction, % |
2.0 |
3.5 |
0.12 |
|
AKI (KDIGO stage ≥1), % |
5.9 |
9.8 |
0.01 |
|
Bowel ischemia, % |
0.9 |
2.0 |
0.16 |
|
Wound infection, % |
0.8 |
6.5 |
<0.001 |
|
Length of stay, days (median [IQR]) |
2 [1–3] |
7 [6–10] |
<0.001 |
EVAR showed the anticipated early safety/LOS benefit versus OSR.
Table 3. Six-year effectiveness outcomes (KM estimates)
|
Outcome at 6 years |
EVAR |
OSR |
Adjusted HR (EVAR vs OSR) |
p-value |
|
All-cause mortality |
29.1% |
24.0% |
1.19 (1.01–1.41) |
0.04 |
|
Aneurysm-related mortality |
3.4% |
1.6% |
1.71 (1.02–2.97) |
0.04 |
|
Late rupture |
3.9% |
1.8% |
1.82 (1.05–3.17) |
0.03 |
|
Any reintervention |
16.0% |
9.2% |
1.58 (1.22–2.05) |
<0.001 |
There was a small disadvantage in long-term survival and the number of aneurysm-specific failures after EVAR was larger, consistent with high-quality observational data and some extensions of RCTs.
Table 4. Sac dynamics after EVAR and long-term outcomes
|
Sac status at 1–2 years (EVAR only) |
Proportion |
6-yr reintervention |
6-yr rupture |
6-yr mortality |
|
Regression ≥5 mm |
54% |
9.1% |
1.2% |
24.5% |
|
Stable (±4 mm) |
34% |
18.7% |
3.9% |
31.0% |
|
Expansion ≥5 mm |
12% |
36.9% |
11.6% |
38.8% |
Lack of regression or expanded sac were strong predictors for late events, supporting the concept of risk adjusted surveillance strategies.
Table 5. Causes of late reintervention (EVAR vs OSR)
|
Indication |
EVAR (n reinterventions=102) |
OSR (n=37) |
|
Type II endoleak with sac growth |
28% |
– |
|
Type I/III endoleak |
22% |
– |
|
Limb occlusion/stenosis |
18% |
11% graft limb occlusion |
|
Open conversion for sac growth/rupture |
14% |
32% anastomotic pseudoaneurysm |
|
Other (migration, infection, access) |
18% |
57% incisional hernia repair/other |
EVAR failures were primarily driven by endoleak and sac behavior, while OSR interventions for non-aneurysmal problems (e.g., hernia) were less common.
Table 6. Surveillance and cost-related utilization
|
Metric (per patient-year) |
EVAR |
OSR |
p-value |
|
Imaging encounters (CTA/DUS) |
1.6 |
0.7 |
<0.001 |
|
Clinic visits related to index repair |
1.1 |
0.5 |
<0.001 |
|
Estimated cumulative Medicare-equivalent spend at 6 yr* |
Higher |
Lower |
– |
Directional cost discovery agrees with a recent study showing increased total costs following EVAR, because of surveillance and reintervention.
OUR multicenter cohort has reinforced 3 resolute tenets in the EVAR–OSR arguments. First, it remains the case that EVAR definitely affords an early peri-operative advantage (of lower 30-day mortality, fewer major complications and reduced length of stay), as RCT meta-analyses and umbrella reviews continue to confirm. 13 Second early advantage of EVAR that diminishes with time; 6 years we found a slight increase of all-cause mortality after EVAR and more signals for aneurysm-specific failure (late rupture, ARM, reintervention). Our own data replicate the 15-years wisdom of EVAR-1 that late aneurysm-related outcome with EVAR is inferior and the ongoing reintervention excess in DREAM extension but also with the large Medicare study showing a worse long-term mortality/rupture pattern with EVAR. 14 The VA OVER trial also demonstrated comparable long-term survival based on strategy and suggests results may be dependent on patient cohorts (ie, comorbid burden of Veterans), timing of device era utilization, and degree of surveillance. 15
Thirdly, sac evolution following EVAR is key. Failure of sac regression or sac expansion at 1–2 years strongly predicted late events in our study, mirroring multi-institutional evidence and prompting risk-adapted surveillance endorsed by ESVS 2024. 16 These data argue for protocolized 1- and 2-year imaging as actionable checkpoints: regression enables de-escalation; stability/expansion warrants intensified imaging and endoleak management. 17
Our results also reflect anatomy and IFU adherence as hidden confounders. Hostile necks, large diameters, and off-IFU deployments portend endoleak, sac growth, and late rupture. Contemporary guidelines therefore emphasize careful selection of EVAR vs OSR and appropriate use of adjuncts/fenestrated technology when indicated. 18 Moreover, population-based studies show that although EVAR usage continues to rise, guideline adherence is variable, and late rupture after EVAR—while uncommon—remains clinically meaningful and resource-intensive when it occurs. 19.
For older or high-risk patients, EVAR’s early safety often dominates, provided robust follow-up is feasible. For younger/low-risk patients with favorable anatomy and long life expectancy, OSR may offer superior durability with fewer late reinterventions and less surveillance burden—an increasingly recognized trade-off in observational cohorts and cost analyses. 20,21 Shared decision-making should incorporate patient comorbidity, anatomy, center expertise, and the capacity for lifelong surveillance.
Limitations: Retrospective design, potential residual confounding, device heterogeneity across years, and center-specific surveillance practices. Nevertheless, outcomes and effect directions align with RCT extensions, large registries, and 2024 guideline syntheses, enhancing external validity.
EVAR remains the safer peri-operative approach but entails greater long-term surveillance and reintervention and a non-trivial risk of late rupture, whereas OSR offers greater durability with fewer AAA-specific failures at long follow-up. Optimal outcomes demand tailored selection, strict IFU adherence, and sac-based, risk-adapted surveillance after EVAR.
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